Under the Radar: Low Rates of Dual-Energy Radiograph Absorptiometry Screening and Associated Fracture Risk in Female Total Shoulder Arthroplasty Patients.

Abstract

Osteoporosis is prevalent in patients undergoing total shoulder arthroplasty (TSA) and affects perioperative management and outcomes, including fragility fractures. Despite guidelines recommending dual-energy radiograph absorptiometry (DXA) screening in women at risk for osteoporosis, screening before TSA remains low. With TSA procedures rising, it is important to identify factors that may contribute to low DXA utilization rates. This study aims to (1) evaluate the influence of demographic and social determinants of health on preoperative DXA screening and (2) identify predictors of postoperative fragility fractures. We retrospectively reviewed female patients who underwent TSA from 2016 to 2024 by a single surgeon. Patients meeting guideline-based indications for DXA were included. Multivariable logistic regression identified predictors of DXA utilization. Among patients without prior fragility fractures, time-to-event analysis using Firth penalized Cox regression assessed predictors of postoperative fractures. A bootstrap sensitivity analysis (1,000 iterations) evaluated the stability of smoking-related risk estimates. Of 432 eligible women, only 39.7% (n = 176) received a preoperative DXA screening. In adjusted analysis, married patients had 52% higher odds of receiving screening (odds ratios 1.52, 95% confidence intervals [1.01 to 2.29], P = 0.044), whereas those with public insurance had 54% lower odds compared with privately insured patients (odds ratios 0.46 [0.29 to 0.74], P = 0.001). Among 358 patients without prior fragility fractures, current tobacco use markedly increased postoperative fracture risk (hazard ratios [HR] 14.87 [1.69 to 130.88], P = 0.015). Higher body mass index was protective: overweight (HR 0.27 [0.08 to 0.87], P = 0.028) and obese (HR 0.03 [0.003 to 0.29], P = 0.002) patients had a lower fracture risk. DXA screening is underused in women undergoing TSA. Marital status and insurance type markedly affect screening rates, whereas low body mass index and tobacco use remain strong predictors of fragility fractures. These findings suggest a need for comprehensive bone health management strategies, including improved screening, risk counseling, and optimized osteoporosis management. III.